Professional Documents
Culture Documents
PII: S0197-4556(16)30238-6
DOI: http://dx.doi.org/doi:10.1016/j.aip.2017.08.005
Reference: AIP 1473
Please cite this article as: Potash, Jordan S., Bardot, Heidi., Moon, Catherine
Hyland., Napoli, Michelle., Lyonsmith, Angela., & Hamilton, Megan., Ethical
Implications of Cross-Cultural International Art Therapy.The Arts in Psychotherapy
http://dx.doi.org/10.1016/j.aip.2017.08.005
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Ethics International Art Therapy p. 1
Art Therapy Program, The George Washington University, Alexandria Graduate Education
Center, 1925 Ballenger Avenue, Suite 250, Alexandria, VA 22314, jpotash@gwu.edu
Heidi Bardot, MA, ATR-BC, LCPAT
Art Therapy Program, The George Washington University, Alexandria Graduate Education
Center, 1925 Ballenger Avenue, Suite 250, Alexandria, VA 22314, hbardot@gwu.edu
Catherine Hyland Moon, MA, ATR-BC
Art Therapy Department, School of the Art Institute of Chicago, 37 S. Wabash, Chicago, IL
60603, cmoon@saic.edu
Michelle Napoli , MA, ATR-BC, LMHC
Expressive Arts Therapy Emphasis in Clinical Mental Health Counseling Department, William
James College, 1 Wells Ave, Newton, MA 02459, michelle_harris01@williamjames.edu
Angela Lyonsmith, MAAT, ATR-BC
Art Therapy Department, School of the Art Institute of Chicago, Gather, 602 Davis
Evanston, IL 60201, alyonsmith@gmail.com
Megan Hamilton, MA, LPCA
Birch Counseling, 3325 Durham-Chapel Hill Blvd, Suite 205, Durham, NC 27707,
meg.hamilton@birchcounselingdurham.com
Corresponding Author:
Catherine Hyland Moon, MA, ATR-BC
Art Therapy Department, School of the Art Institute of Chicago, 37 S. Wabash, Chicago, IL
60603, cmoon@saic.edu
Editor’s Note:
This paper was developed from a panel delivered by the authors titled “Conducting Cross-
Cultural Art Therapy Internationally: Ethical Implications” at the American Art Therapy
Association Annual Conference in San Antonio, TX on 12 July 2014.
Highlights
Abstract
Art therapists are increasingly offering their services in international contexts. Although usually
altruistic in nature, unexamined practices can result in detrimental consequences to both the
Ethics International Art Therapy p. 2
travelers and host communities. A consideration of the ethical dilemmas that one might face can
better orient art therapists to the many aspects of offering art therapy abroad. Preparation for
competence, and ensuring sustainable practices. While in country, there are considerations
pertaining to art materials, studio space, service delivery, artworks, roles, positions of power, and
including through reporting and fund-raising, is crucial. A critical look at the ethics and values
involved in providing art therapy internationally can help ensure that art therapists offer global
Due to globalization, increasing numbers of people and organizations have been involved
proliferation of art therapists have travelled across international borders to provide disaster
Anderson, 2013; Arrington, 2013; Kapitan, Litell & Torres, 2011; Moon, 2013; Wallingford,
Hamilton, Kirschner, Palladino, & Tosatto, 2013). Typically, art therapists from high-income
countries (HIC) travel to low or middle-income countries (LMIC) for a limited period of time,
technical expertise, or develop cultural competence. Both service recipients and travelers may
learn new skills, broaden their perspectives, and widen their professional networks, but travelers
may also experience complex ethical questions about cross-cultural international practice.
Ethics International Art Therapy p. 3
The art therapy literature about international work seldom addresses the ethics involved.
Conducting ethical work outside one’s home country requires continuous examination of cross-
cultural ramifications of power and privilege. When international work is framed as helping or
empowering people, there are often overlooked implicit biases that: a) those requiring help have
limited power, b) there is a radical division between “us” and “them,” and c) those with more
resources hold exclusive rights to empowerment, wellness, and fulfillment. While most art
therapists would deny this colonial logic, research suggests that it may unconsciously hold sway
(Watson, 2013). A common assumption is that Western psychology as implicitly more valid,
developed, and valuable than folk or ethnic healing systems. In reality, Western psychotherapy is
also culturally determined and exists among many other contemporary, relevant psychological
healing practices across the globe (Christopher, Wendt, Maracek, & Goodman, 2014; Mills,
2014a; 2014b).
To examine some of the ethical implications of conducting art therapy internationally and
to identify best practices, we reviewed literature by art therapists and other mental health
professionals and critically reflected on our own work. Although we are all based in the United
States, collectively we have worked across the globe: Potash in Hong Kong, China; Bardot in
India, Lebanon, United Arab Emirates, France, Croatia, South Africa; Moon and Lyonsmith in
For this paper, we define international work as contributing art therapy informed
knowledge and skills to projects outside one’s country of residence. Visitors are those who
engage in such work, and the host community is the international destination where an exchange
takes place. For simplicity’s sake, we use the term art therapy in this article, even though a
number of us intentionally refer to our international work with alternative terms (for example,
Ethics International Art Therapy p. 4
therapeutic arts or art as therapy). Art therapy often implies a specific Western concept, while
these alternative terms encompass a wider array of arts in health and healing practices and
demonstrate respect for the profession of art therapy in countries where it is regulated.
Many professionals see ethical behavior as a means to guard against liability. Knapp and
VandeCreek (2006) stressed, “ethics can be viewed as a voluntary effort to ‘do the right thing,’
motivated by deeply held moral principles” (p. 3). Basing ethical decision making on aspirational
or positive values promotes increased context-specific critical thinking, rather than generalized
prescriptive principles (Hinz, 2011; Hunt, Schwartz, Sinding & Elit, 2014). The five traditional
aspirational values include: autonomy (participants’ right to informed decision making), non-
maleficence (do no harm), beneficence (promote good and wellness), fidelity (honesty and
integrity), and justice (fairness in access to resources). The Ethical Principles for Art Therapists
(American Art Therapy Association (AATA), 2013) identifies a sixth value of creativity.
Depending on the international context, art therapists may find that ethical principles
based on Western philosophies and worldviews fail to cover the nuances of their work. These
ethical codes emphasize individualism, autonomy, and boundaries between people and thus fall
short when applied to cultures oriented toward collectivism, interdependence, and interpersonal
connections (Pettifor, Sinclair & Falender, 2014). Given such uncertainty, international health
care professionals are prone to moral stress, defined as feelings of “insufficiency, powerlessness,
meaninglessness, and frustration,” (Nilsson Sjöberg, Kallenberg, & Larsson, 2011, p. 66).
Because most ethical codes fail to address the unique challenges of working internationally (for
an exception, see Universal Declaration 2008), it is important for art therapists to adopt a
framework that is self-reflexive to mediate among individual, cultural, economic, and political
Ethics International Art Therapy p. 5
realities (Thoburn, Bentley, Ahmad & Jones, 2012). The goal is not mastery of a set of skill set,
but rather ongoing critical reflection, cultural humility, and openness to the complex interaction
of diverse worldviews. Since real-world examples are a more effective means to hone “good
moral ‘reflexes’” than general, abstract principles (Hunt, Schwartz, & Elit, 2012, p. 96), this
article provides examples of our first-hand experiences. Our overall aim is to identify potential
ethical issues and guiding principles, rather than to address the nuances of each specific situation.
Preparation
to share professional expertise abroad. While rooted in beneficence, such work also calls to
mind the value of fidelity. An overarching consideration pertains to working within one’s area
of competence: “Art therapists refrain from using art materials, creative processes, equipment,
technology, or therapy practices that are beyond their scope of practice, experience, training, and
education” (AATA, Principle 6.2). A common critique of volunteer tourism is that travelers
adopt the role of expert when they may not only lack requisite skills and knowledge, but also
know little about the communities within which they are working (Guttentag, 2009; Palacios,
2010). Such an approach “raises the specter of neo-colonialism in the tacit assumption that even
ignorant Westerners can improve the lot of the people in the [global] South” (Brown & Hall, as
cited in Palacios, 2010, p. 863). Posing critical questions is essential. For example, while
engaged in a graduate art therapy program’s service learning trip to Cambodia, Hamilton and her
fellow participants wanted to ensure their readiness before accepting an invitation to work in an
orphanage. They assessed their knowledge regarding the specific organization and the cultural
circumstances under which Cambodian orphanages operate. Some questions they considered
included: How would accepting the invitation benefit the children, the orphanage, and the
Ethics International Art Therapy p. 6
student group? How might it cause harm? Might such a decision perpetuate systemic problems
caused by dependence on international volunteers? Might it potentially exploit the children, the
Assessing Motivations
attitudes and practices can perpetuate inequality in any cross-cultural situation (Sajnani, 2012;
Talwar, 2010), but in international contexts these dynamics can be complicated by competing
humanitarian, political, and economic agendas among international providers, host communities,
workers focus only on the perceived benefits of their services related to compassion, moral
obligation, and reparation, but fail to take into account the perils of short-term inefficiencies and
“a neo-colonial, or imperialist relationship between ‘recipients’ and ‘donors’” (Sumner & Tribe,
2011, p. 790).
Such power inequities are present when international workers take on features of the
White Savior complex by “rescuing” others who are deemed poor, needy, and powerless
(Hughey, 2010; Zeddies & Zsuzsa, 2015). Cole (2012) described a person with this complex as
one who values personal emotional experience over justice, “supports brutal policies in the
morning, founds charities in the afternoon, and receives awards in the evening” (para. 1).
Although many volunteers traveling to LMICs identify as White, it is important to note that
White Savior is not an indication of racial identity, but rather a signifier for unexamined power
and privilege. Anyone who has the resources to undertake international travel for the purposes
encounter, potential impact on the host community, desired personal gains, and the influence of
various constituencies on the direction and aims of the work. Visual journaling may be
especially helpful for recognizing otherwise unexamined negative, positive, or pseudo positive
biases and attitudes (Shannon-Baker, 2015). Moon and Lyonsmith found that participants in
programs in Kenya and Tanzania often romanticized the East African lifestyle as much more
relaxed than the hectic pace of U.S. living. The participants failed to take into account that the
“relaxed lifestyle” has come, in part, from high unemployment and poverty, which, in turn, is
related to the long-term effects of colonialism and neoliberal global politics. Trip and project
leaders are responsible for ensuring that visitor preparations include educational materials about
the historical realities and current impact of imperialism. Denying or remaining ignorant about
this influence enables the visitor to encounter locales as unspoiled, authentic, and unchanged.
Yet this very perceptual stance replicates the colonized/colonizer relationship by positioning the
host culture as an undeveloped site that is a prime target for modernization by foreign influences
Sue and Sue (2016) identified three components of cultural competence as self-
awareness, knowledge, and skills. Self-awareness includes examining one’s values, worldviews,
beliefs, assumptions, and biases and how they impact cross-cultural relationships. Knowledge
entails learning about another’s customs, values, language, and history, as well as how the host’s
culture intersects with one’s own culture. Skills pertain to working effectively within the norms
and expected practices of the other’s culture. Critiques of cultural competence point to the
Ethics International Art Therapy p. 8
mistaken belief that culture is a static concept that can be mastered and to its lack of a
transformative social agenda (Fisher-Borne, Cain, & Martin, 2015). Cultural humility, on the
other hand, emphasizes “an interpersonal stance that is other-oriented rather than self-focused,
characterized by respect and lack of superiority toward an individual’s cultural background and
experience” (Hook, Davis, Owen, Worthington & Utsey, 2013, p. 353). It calls for the mitigation
To instill cultural humility, orientation to a new country ought to include materials that
disrupt embedded stereotypes about both people and place. Ideally, before attempting to do work
in a foreign country one would learn the local language, conduct an in-depth study of the culture,
and live in the locale for an extended period of time. However, the duration of most international
work is brief. Further, command of the language, cultural values, and intricacies of intracultural
dynamics are unlikely. Calls to deepen social justice pedagogy in art therapy have implications
for international applications (Gipson, 2015; Sajnani, Marxen & Zarate, 2017). Preparing to
work from a culturally humble, decolonizing framework requires learning about the historical,
political, economic, and structural legacies of colonialism and White supremacy. Visitors can
seek counter-narratives to dominant myths about the “Other,” and discuss strategies for de-
understanding health, illness, and healing. Humility, openness to the unfamiliar, and
commitment to learning create a basis for developing knowledge of the host community.
visiting art therapist and fosters attunement to the host culture’s resources and needs.
Consultative relationships establish a basis for privileging local knowledge about cultural beliefs,
mental health practices, and art. Local hosts can help ensure cross-cultural sensitivity by
providing information about common cultural practices as well as prevalent attitudes toward
foreigners. Some strategies to consider when preparing to work internationally include: asking
host communities to set meeting agendas, working collaboratively on goals, co-leading training
sessions, inviting local people to present on their work, recognizing host and visitors
accomplishments, and establishing a budget that includes paying local collaborators for their
establish trust, deepen cross-cultural understanding, and develop shared accountability. Moon
recalls the first time her East African colleagues, after discussing and supposedly agreeing with
her on a plan for an art project they would carry out with local children, implemented an entirely
different plan. Their actions seemed to indicate enhanced trust in their indigenous knowledge as
well as in the strength of the collaboration to withstand conflict. Over the years, as trust and
understanding have continued to develop, differences of opinion have been more overtly
expressed by all involved. The preparation necessary for creating healthy cross-cultural
ongoing support structures for self-assessment, contextual exploration, and supervisory oversight
during and after the visit (Canfield, Low, & Hovestadt, 2009; Hammersley, 2014). Trip leaders
Ethics International Art Therapy p. 10
have an ethical responsibility to ensure regular supervision and consultation. The needs and
participants and collaborators— must be considered. The challenge for trip leaders is to establish
an environment wherein local perspectives and agendas are privileged, but mutual learning,
Culture shock, the sense of disorientation people often experience when encountering
assimilation” (p. 328). Progression through all of these phases typically requires prolonged
engagement in a new cultural context, though people on short-term assignments may experience
some of them. However, international work does not inevitably leads to culturally sensitive
development. Without proper supervision and opportunities for reflection, travelers might
interpret and judge their experiences based on the dominant social and cultural perspectives of
their home countries, exoticize their cross-cultural encounters, and fail to recognize meaningful
changes in their perspectives, motivations, and relationships with other travelers, host
community members, and the people they eventually return to in their home country (Bamber,
2015).
Bardot (2011) invited her graduate art therapy students to participate in a daily arts-based
experience to promote expression, grounding, and reflection in relation to the community service
they provided as part of their study trip. The students created an image in response to the day’s
events and interactions, engaged in reflective writing, and then shared their art with their fellow
Ethics International Art Therapy p. 11
students. The resulting artwork was then hung in a public space, becoming part of a group art
piece. By the end of the trip, each individual had an art journal and the group had an overall
record of their collective challenges and learning. Activities such as this help students avoid
fragmentation that may come with culture shock, while also exploring their own cultural identity
Service Delivery
The emerging field of global mental health has addressed the paucity of mental healthcare
in LMICs and taken into account complicating factors, such as stigma, poverty, social inequality,
gender discrimination, and environmental injustice (Ngui, Khasakhala, Ndetei, & Roberts, 2010;
O’Donnell, 2012). However, global mental health also has been widely criticized for its reliance
on Western concepts of mental health and illness, as well as its ethnocentric understandings of
social relations and norms related to personhood, privacy, emotional display, children’s
development, gender roles, spiritual beliefs, family constellations, etc. (Christopher, et al., 2014;
Likewise, art therapists cannot simply rely on ethnocentric assumptions about the nature
of art and its relationship to healing. The conceptual understanding of art therapy and how it is
practiced varies from place to place (Karkou, Martinsone, Nazarova & Vaverniece, 2011).
Ideally, art therapists are able to switch between an individualistic and a collectivistic lens, as
well as between ethnocentric and ethnorelative perspectives (Kapitan, 2015). While art therapists
may conceive of the arts as means for self-expression and healing, other project stakeholders
may consider the arts to be evidence of achievement, a means for education or activism, or
culturally embedded components of spiritual and communal rituals (Huss, Kaufman, Avgar, &
Shouker, 2015). The complex dynamics among conceptions of health, art, and therapy within a
Ethics International Art Therapy p. 12
given cultural context will largely determine the nature and scope of art therapy in that locale
Building Relationships
between cross-cultural partners to ensure sustainability. Art therapists are required to “avoid
boundaries in relation to beginnings and endings. Unlike art therapy practice undertaken in
one’s home country, international work is often characterized by short-term contact, either one-
off or structured through repeated visits with large breaks between. The nature of the relationship
between the hosts and visitors should be clearly and collaboratively established, including both
what happens while visiting art therapists are in the host country as well as what happens once
the visit has ended or between visits. An honest discussion of reasonable objectives, goals, and
leaders (AATA, Principle 6.4) helps ensure that art therapists provide high quality, site-specific,
culturally informed, and locally supported services. To establish the tenor for ongoing
international collaborations Moon (2013) suggests honoring the principles of reflexivity (taking
into account one’s assumptions and privilege), power sharing (working from the basis of hosts’
and visitors’ mutual expertise), cultural relevance (privileging local perspectives and expertise),
Cross-cultural international art therapy includes: direct service, relief work, training, and
the host community. It is imperative to work with local partners to develop context-sensitive and
responsive services, and to establish a plan for what will happen when the visiting art therapists
leave. Determining clear goals for the work can be accomplished through discussion and arts-
based explorations with local community partners, and can lead to co-creating positive,
embedded in local programs or working from a community studio model is often preferable to
initiating clinical work. A studio model provides flexibility and helps to normalize a situation in
acceptable or useful in a given cultural context (Kalmanowitz & Ho, 2016; Kalmanowitz &
Lloyd, 2011). An art psychotherapy approach, in contrast, is potentially harmful if time with
Relief work is a specific form of direct service that occurs in the context of trauma
including war, terrorism, or civil conflict. Such work is particularly challenging when traumatic
events are massive, ongoing, and multigenerational. It is important to balance the urgent need for
assistance with the ethical responsibility to adequately understand the community’s historical
relationship and response to traumatic incidents (Kira, 2010; Makhashvili et al., 2010).
meanings, consequences, and means of recovering are culturally determined (Marsella, 2010). A
participation in mental health services may lead to stigmatization that destabilizes aspects of
identity that are key to well-being and resilience (Trivedi, 2014). So-called symptoms are often
Ethics International Art Therapy p. 14
(Goodman, 2015). Listening for the ways that local people and communities understand trauma
and supporting their indigenous strategies for regaining equilibrium are key to a decolonizing
approach to art therapy (Kalmanowitz & Ho, 2016; Miller-Graf, 2016; Stein & Illes, 2015).
While theories and practices of trauma specific art therapy in HICs have been addressed
(i.e. Chapman, 2014; Klorer, 2017; Malchiodi, 2014), there has been little research on the
effectiveness of these approaches in LMICs. General principles of trauma informed care, such as
collaboration, focusing on strengths, and emphasizing choice, control, and psychological safety
are all consistent with commonly accepted ethical standards for global mental health practice. In
addition, the creative arts therapies provide opportunities for connection with cultural traditions
and rituals, which can reinforce collective resilience (van Westrhenen, Fritz, Oosthuizen,
Lemont, Vermeer, & Kleber, 2017). Inviting survivors to tell their trauma stories, even through
indirect art-based expression, may have negative effects. Studies with war-affected adolescents
indicated future orientations and avoidance of dwelling on feelings correlated with better mental
Treatment involves not only addressing individual trauma, but also providing
routines, and self-healing processes. Goals associated with community arts events, spiritual
ceremonies, community based care, and social enterprises can help to mobilize resources,
support reengagement in daily functioning, and maximize well being (Huss, Kaufman, Avgar, &
selecting the types of services to offer (Kalmanowitz, 2014). In the immediate aftermath of a
Ethics International Art Therapy p. 15
crisis, service recipients may require structure, order, and safety rather than psychotherapy.
Those who are not in immediate danger may benefit from using art for expression, reflection,
and meaning-making, while people in situations of ongoing threat may require multiple forms of
treatment, such as psychological first aid, psycho-education and affect regulation strategies
physiological response, become more open to new information, address numerous losses,
promote group cohesion, foster self-care strategies, and improve overall quality of life (Gordon,
Staples, He & Atti, 2016; Ho, Potash, Lo & Wong, 2014; Kalmanowitz & Ho, 2016). When
Bardot worked with refugees in Lebanon, addressing the multiple layers of trauma and loss
required a variety of approaches – community work, art, movement, poetry, and drama. To make
this practice sustainable, a collaborative approach included the relief workers, counselors,
educators, and social workers, all who were refugees experiencing their own trauma responses.
Training refers to visiting art therapists engaging with host collaborators in a reciprocal
cross-cultural exchange to learn about therapeutic and healing applications of the arts. In
countries that have yet to develop widely available art therapy educational or organizational
structures, a focus on paraprofessional training can honor indigenous knowledge, methods, and
pioneers of healing art practices while also acknowledging the advanced professionalism of the
field in other parts of the world. Lay counselors who have received culturally responsive,
context-specific training and supervision have helped fill gaps in LMICs where there is a severe
shortage of mental health professionals, and have delivered effective mental health services
resulting in symptom reduction (Miller-Graf, 2016; Woods-Jaeger, Kava, Akiba, Lucid, &
Dorsey, 2010) and post-traumatic growth (Gregory & Prana, 2013). Nonprofessionals can
Ethics International Art Therapy p. 16
provide supportive listening, information, help with accessing services, strategies for self-care
and wellness, and communal arts opportunities that foster social integration and collective
aspects of art making, such as materials, themes, and interpretation, in order to determine how
these aspects are understood and implemented within local therapeutic arts practices
(Kalmanowitz & Potash, 2010). Built into this way of working is an acceptance of the art
therapist’s impermanence in the community and the desire to help the host community achieve
self-sufficiency (Moon, 2013). Co-teaching and collaborating with local providers helps ensure
In addition to direct service and training, art therapists frequently offer consultation and
supervision services to support existing programs. Consultation involves offering one’s views or
supervision is offered to support, assist with problem-solving, and encourage ongoing learning in
those previously trained. When working in the Sichuan province of China following an
earthquake, Potash joined a team of creative arts therapists, one of who remained in the host
community for a year following the initial training to offer guidance (Ho, et. al, 2012). Other
Local constituents should be consulted when determining the type of art therapy offered
and the potential long-term effects of foreign interventions. As a first step in exploring the
development of therapeutic art programs for vulnerable children in East Africa, Moon visited art
centers, mental health treatment programs, and other social service sites in Arusha, Tanzania to
Ethics International Art Therapy p. 17
talk with social workers, teachers, principals, artists, and other professionals who could inform
her about the support structures already in place, the ways problems and potential solutions were
locally understood, the capacity of community caregivers, and the role the arts played in relation
to health and healing. These consultations resulted in shifting the proposed plan from building an
art therapy center in Arusha to supporting the work of artists and other cultural workers in
multiple sites across Tanzania and Kenya. The focus of the program since that time has been to
The potential for harm in international projects should be critically evaluated both prior
to their undertaking and throughout their implementation, given the art therapist’s outsider status
and ambiguous responsibility to the local community. Conceivable harmful impacts include:
performing work for free that undermines the local labor market, promoting dependency by
ignoring local expertise and reinforcing the myth of Western superiority, performing services the
community does not desire or need, offering services by unskilled or culturally uninformed
volunteers who do unsatisfactory work and/or interfere with the progress of a project, doing
work in hospitals or schools that would be prohibited in one’s home country (Guttentag, 2009),
providing mental health services without sufficient follow-up, and offering art materials or
processes that create interest and desire among host community members but that are not locally
Fair Trade Learning principles offer a set of ethical guidelines that may help art therapists
avoid such harmful practices. These principles are relevant not only for study trips, but also for
any global exchange “that prioritizes reciprocity in relationships through cooperative, cross-
cultural participation in learning, service, and civil society efforts” (Hartman, Paris & Blanche-
Cohen, 2014, p. 109). Core priorities include “economic equity, equal partnership, mutual
Ethics International Art Therapy p. 18
learning, cooperative and positive social change, transparency, and sustainability” (p.110). The
intent of the principles is to foster balanced benefits among visiting volunteers, sponsoring
Providing art materials, offering a reliable art studio, and maintaining the integrity of the
resulting artwork are all integral to the work of art therapy and prompt ethical considerations. A
culturally competent approach to art materials involves investigating the traditional arts practices
and available art materials in the host community. When working with an ethnic minority group
in China, Potash and Kalmanowitz (2012) discovered that even though Western art materials
were readily available, cultural tradition dictated the nature of their use. For example,
experimentation with drawing and sculpture did not necessarily extend to paint, which was used
Although the choice of art materials is often framed within therapeutic intentions, this
choice also carries with it economic, relational, and environmental considerations (Hartman,
Paris & Blanche-Cohen, 2014; Moon, 2010). Bringing materials from one’s home country may
fulfill needs or desires of the host community and may also function as an expression of
culturally appropriate gift giving. On the other hand, doing so can foster dependence, prevent
recognition of local resources, and undercut income for local art material suppliers. Additionally,
the question of sustainability is raised when materials are not locally available. When working in
Guatemala, Napoli and her fellow service providers aimed to identify local, sustainable,
accessible, and culturally respectful materials for community arts engagements. They
incorporated the procurement of art supplies into the cross-cultural training experience by having
visiting art therapy students shop for materials in local markets, relying on a budget that was
Ethics International Art Therapy p. 19
comparable with what would commonly be available to local community members. Art
therapists may also rely on found objects and natural materials (Kalmanowitz & Lloyd, 2011).
Even when sourced locally, art therapists should note the cultural meanings ascribed to
potential art materials. In Guatemala, Napoli and her colleagues found markers, crayons, paper,
paint, and colored pencils to be too expensive and not easily accessible in rural villages. Items
from the market such as incense, corn, and beans were only appropriate for use in Mayan
ceremonies and religious practices. After consultation with local community members, visiting
art therapists learned to use regional raw materials such as wood, thin plant fibers, corn husks,
In some countries, the use of art materials for non-utilitarian purposes is called into
question because it implies an economic privilege that is incompatible with local needs and
resources. Whether materials are local or foreign, traditional or unconventional, art therapists
must also determine if there is adequate infrastructure for cleaning and disposal of art materials’
byproducts or excess. In areas with limited water supplies or waste management systems, many
art materials may present environmental hazards (Moon, 2010). It is also important to be
materials. Incorporating art modalities such as drama and movement, which do not rely on
Ethically, art therapists are obligated “to provide a safe, functional environment in which
to offer art therapy services,” one that allows for privacy and confidentiality (AATA, Principle
1.8). The concept of private space implies a position of privilege that is embedded within
individualistic societies. Not only may such spaces be unavailable, but they also may be
Art therapists are expected to store and retain client “artwork, photographs or digital
images” (AATA, Principle 4.7). Underlying this ethical principle are individualistic, capitalist
consider what will happen to the art produced and who will ultimately take ownership of it. In
some contexts, there may be little expectation, desire, or opportunity to store finished artworks.
For example, Lyonsmith and Moon recognized that it would be impractical to expect families in
the Kibera slum of Nairobi to store art products in their homes, as the tiny dwellings were set up
to prioritize basic needs such as sleeping and cooking food. In such situations, when individual
and collective decisions at the local level determine what happens to the art, both ethical
art for personal insight, self-expression, and problem solving. In international settings, it is
important for art therapists to consider the burden such emphases may place on participants. Art
pieces that represent the harsh realities of life may cause stress for families and the community.
Efforts to understand local metaphors, idioms, and subject matter increase the likelihood
that directives will be context-sensitive and that possible interpretations of artwork will be more
closely aligned with the intentions of the maker. The Western-based assessment, “Draw a
Person in the Rain,” is assumed to relate to stress, but this interpretation is dependent on an
individual’s experience of rain (Graves, Jones & Kaplan, 2013). In an arid climate, rain can
signify blessings (Potash & Doby-Copeland, 2011). Longstanding art therapy interpretations
that equate psychological pain with drawing characteristics, or seemingly innocuous directives
such as drawing one’s feelings, creating body outlines, or designing mandalas (Anderson, 2013;
Ethics International Art Therapy p. 21
Arrington, 2013; Chu, 2010; Liebmann, 2013) should be examined for cultural biases, values,
and taboos. Art therapists can integrate cross-cultural symbol associations, culturally specific
meanings, and social-political contexts in order to arrive at context sensitive interpretations that
maintain host community narratives and consider the social construction of meaning (Huss,
When possible, art therapists should secure written consent from participants in
educational or therapeutic programs and their authorizations for documenting and photographing
sessions and artwork. Written documents should be in the language of the local community.
Informed consent for workshops, arts based projects, and trainings are intended to ensure that
participants are fully aware of the identity of the professional or group involved, the intentions of
the facilitator(s), the duration of the project, the aims of the program, and the benefits and
outcomes they should expect as a result of participating. Local participants should also be made
aware of whether they are working with students or professionals and of any benefits (financial,
academic credit, etc.) the travelers will receive for facilitating or participating in a program.
should explicitly state the purposes for which the photos will be used (documentation,
provisions can be made for photographs to be offered to the local community for their own use.
If it is the tradition of the community, or if literacy is a problem, then verbal consent and
authorization may suffice. In such circumstances, permission may be gained from recognized
witnesses from the host community (Tindana, Kass, & Akweongo, 2006).
Ethics International Art Therapy p. 22
Accountability
Art therapists’ accountability to multiple stakeholders can cause conflicts of interest due
to the diverse agendas at play and the range of political, economic, and social capitol held by the
agreements for service delivery and allocation of funds. Ideally, members of the host community
are the ones who determine if project goals have been satisfactorily achieved.
Honoring Stakeholders
activities, and post-travel follow-up, art therapists are accountable to various groups of people
who each have their own stake in the project. Art therapists have the ethical responsibilities of
refraining from exploitation and being truthful in representing services and fees (AATA,
Principles 11.2 and 11.4). Because expectations may vary widely among stakeholder groups and
individuals, it is important to clarify program costs, goals, objectives, and anticipated outcomes.
Being as clear and transparent as possible helps ensure that all stakeholders are treated with
from the host community and/or the visitors’ home country. Local collaborators might expect to
gain skills and knowledge, increase financial support, gain local legitimacy through U.S.-based
therapists who organize trips are accountable to visiting students and professionals whose
expectations might include any of the following: being educated, providing direct service,
sharing their knowledge and skills with other professionals or trainees, acquiring souvenirs or
Ethics International Art Therapy p. 23
mementos, taking part in cultural experiences, and making long-lasting connections with people
from the host community. Trip organizers also might be accountable to educational institutions
or non-profit organizations that sponsor and/or fund the trips, as well as organizations on the
ground in the host country. These entities may have a range of expectations, such as trip
organizational mission, revenue production, problem solving, fundraising, and research. Beyond
project stakeholders, art therapists working internationally are accountable to the profession of
art therapy, to represent it accurately and uphold its ethical principles. Further, there is a
documentation procedures. Culturally appropriate processes are most likely when visitors
collaborate with stakeholders from the host community to identify the goals of the project, to
create a set of program evaluation questions, and to revise evaluation procedures as needed.
Aside from traditional reporting strategies, arts-based research methods can be embedded in
evaluation methods to ensure that community voices retain a central position (Huss, Kaufman,
Hamilton and her colleagues in Cambodia worked with community partner agencies to
develop a survey and end-of-project evaluation for project participants, local collaborators, and
visitors. Even with this collaborative approach, there remained questions as to whether or not a
survey was the most appropriate way to get feedback about the work. It became clear that the
surveys overlooked cultural nuances and influential factors that would likely skew the data. The
Ethics International Art Therapy p. 24
feedback collected from various stakeholders has been used to make program adjustments,
In follow-up reports, art therapists involved in international work are responsible for
ensuring that anecdotes and images about the work are presented respectfully and fairly. Because
such representations are not value neutral, they should be carefully analyzed prior to use.
Analysis helps to reveal potential underlying dominant narratives and media stereotypes that
essentialize host cultures as inherently different, exotic, unchanged over time, or inferior and that
perpetuate historical and structural power inequities. Images and discourses that serve to
entrench binary stereotypes about people in need (passive, disadvantaged, exoticized, backward,
victimized) and people who are needed (agentic, advantaged, normative, progressive, heroic)
have no place in reporting on or promoting projects, whether through formal accounts or through
informal sharing via casual in-person contacts or social media. Fair, honest, and respectful
representation occurs when host communities and cultures are presented as complex, multi-
faceted, evolving, dynamic, and globally interconnected (Caton & Santos, 2009).
Acquiring Funding
The costs of traveling abroad can be high, which leads many to seek funding for travel
expenses and remuneration for services delivered through institutional grants or private
the viewer’s emotional response as a means of raising funds. Unfortunately, products of art
therapy are sometimes used for this purpose, flattening complex narratives into marketable
images and stories of suffering, victimization, and helplessness (Edmondson, 2005). Not only
are art therapists ethically obligated to obtain permission to discuss projects and show
photographs of participants and artwork but, also, as noted above, photographs and stories should
Ethics International Art Therapy p. 25
be presented in a way that is honest and that does not exploit or sensationalize participants or
Selling participants’ artwork needs to be done with considerable caution, taking into
account whether the art was made for the purposes of selling or for therapeutic expression.
Profit-sharing arrangements should be carefully discussed with the host communities and
potential funders made aware of how their monies will be used, whether for direct programming,
Conclusion
In this paper, we propose ethical considerations and guidelines for providing art therapy
services internationally. Preparing for travel allows for increased self-awareness, development of
cultural knowledge, and consideration of how one will be perceived as an international worker.
When delivering services, art therapists carefully determine the kind of work needed and how to
best support the host community while honoring art therapy values and practices. Accountability
As the field of art therapy expands and international collaboration becomes increasingly
accessible and commonplace, it is crucial that art therapists develop ethically grounded and
intentionally focused cross-cultural practices. There are inherent tensions between the roles of
expert and collaborator, as well as between adherence to home and host community values.
Rather than providing universal best practices, ethical guidelines reinforce the need for
continuous critical thinking to ensure that art therapy is delivered with the utmost integrity.
Acknowledgements
Ethics International Art Therapy p. 26
The authors would like to acknowledge the many collaborators involved in the programs
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